lOMoAR cPSD| 26582732
Lom oarc ps d| 26582732
Nclex REVISION 2025
Nursing (Harvard University)
DO NOT delegate what you can EAT!
E - evaluate
A - assess
T – teach
Addison’s= Everything is DOWN except Potassium… Mineral corticoids are give in Addison’s
disease. Hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia
Cushings= Everything is UP except Potassium hypernatremia, hypertension, increased blood
vol, hypokalemia, hyperglycemia
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, lOMoAR cPSD| 26582732
No Pee, no K (do not give potassium without adequate urine output)
Elevate Veins
Dangle Arteries ….for better perfusion
A= appearance (color all pink, pink and blue, blue [pale])
P= pulse (>100, < 100, absent)
G= grimace (cough, grimace, no response)
A= activity (flexed, flaccid, limp)
R= respirations ( strong cry, weak cry, absent )
TRANSMISSION-BASED PRECAUTIONS:
AIRBORNE
Measles
Chicken Pox/Varicella Hez - Herpez Zoster/Shingles TB
TB… N95 MASK
SARS
Private Room - negative pressure, Exchange air 6-12 hrs - DOOR CLOSED
Mask, N95 for TB
Gloves
Gown
Handwashing
Disposable supplies
DROPLET
Think of SPIDERMAN!
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()
, lOMoAR cPSD| 26582732
S - sepsis
S - scarlet fever
S - streptococcal pharyngitis P - parvovirus B19
P - pneumonia
P - pertussis
I - influenza
D - diptheria (pharyngeal) E - epiglottitis
R - rubella
M - mumps
M - meningitis
M - mycoplasma or meningeal pneumonia An - Adenovirus
Private Room
Cohort Mask – Pt wears mask when leaving the room
Disposable supplies
CONTACT PRECAUTION
MRS.WEE
M - multidrug resistant organism
R - respiratory infection
S - skin infections *
W - wound infxn
E - enteric infxn - clostridium difficile E - eye infxn – conjunctivitis
SKIN INFECTIONS VCHIPS
V - varicella zoster
C - cutaneous diphtheria H - herpez simplex
I - impetigo
P - pediculosis S – scabies
Private Room- Door Open
Gloves
Gown ONLY worn when in Direct Contact
Disposable supplies
1. Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic,
sense of impending doom) --> turn pt to left side and lower the head of the bed.
2. Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal bradycardia,
etc) --> turn on left side (and give O2, stop Pitocin, increase IV fluids)
3. Tube Feeding w/ Decreased LOC --> position pt on right side (promotes emptying of the
stomach ) with the HOB elevated (to prevent aspiration)
4. During Epidural Puncture --> side-lying
5. After Lumbar Puncture (and also oil-based Myelogram)--> pt lies in flat supine (to prevent
headache and leaking of CSF)
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, lOMoAR cPSD| 26582732
6. Pt w/ Heat Stroke --> lie flat w/ legs elevated
7. During Continuous Bladder Irrigation (CBI) --> catheter is taped to thigh so leg should be kept
straight. No other positioning restrictions.
8. After Myringotomy --> position on side of affected ear after surgery (allows drainage of
secretions)
9. After Cataract Surgery --> pt will sleep on unaffected side with a night shield for 1-4 weeks.
10. After Thyroidectomy --> low or semi-Fowler's, support head, neck and shoulders.
11. Infant w/ Spina Bifida --> position prone (on abdomen) so that sac does not rupture
12. Buck's Traction (skin traction) --> elevate foot of bed for counter-traction
13. After Total Hip Replacement --> don't sleep on operated side, don't flex hip more than 45- 60
degrees, don't elevate HOB more than 45 degrees. Hip abduction by separating thighs with
pillows.
14. Prolapsed Cord --> knee-chest position or Trendelenburg
15. Infant w/ Cleft Lip --> position on back or in infant seat to prevent trauma to suture line. While
feeding, hold in upright position.
16. To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) --> eat in reclining
position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low CHO
and fiber diet, small frequent meals)
17. Above Knee Amputation --> elevate for first 24 hours on pillow, position prone daily to provide
for hip extension.
18. Below Knee Amputation --> foot of bed elevated for first 24 hours, position prone daily to
provide for hip extension.
19. Detached Retina --> area of detachment should be in the dependent position
20. Administration of Enema --> left side-lying (Sim's) with knee flexed
21. After Supratentorial Surgery (incision behind hairline) --> elevate HOB 30-45 degrees
22. After Infratentorial Surgery (incision at nape of neck)--> position pt flat and lateral on either
side.
Downloaded by NELSON KIIRU
()
Lom oarc ps d| 26582732
Nclex REVISION 2025
Nursing (Harvard University)
DO NOT delegate what you can EAT!
E - evaluate
A - assess
T – teach
Addison’s= Everything is DOWN except Potassium… Mineral corticoids are give in Addison’s
disease. Hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia
Cushings= Everything is UP except Potassium hypernatremia, hypertension, increased blood
vol, hypokalemia, hyperglycemia
Downloaded by NELSON KIIRU ()
, lOMoAR cPSD| 26582732
No Pee, no K (do not give potassium without adequate urine output)
Elevate Veins
Dangle Arteries ….for better perfusion
A= appearance (color all pink, pink and blue, blue [pale])
P= pulse (>100, < 100, absent)
G= grimace (cough, grimace, no response)
A= activity (flexed, flaccid, limp)
R= respirations ( strong cry, weak cry, absent )
TRANSMISSION-BASED PRECAUTIONS:
AIRBORNE
Measles
Chicken Pox/Varicella Hez - Herpez Zoster/Shingles TB
TB… N95 MASK
SARS
Private Room - negative pressure, Exchange air 6-12 hrs - DOOR CLOSED
Mask, N95 for TB
Gloves
Gown
Handwashing
Disposable supplies
DROPLET
Think of SPIDERMAN!
Downloaded by NELSON KIIRU
()
, lOMoAR cPSD| 26582732
S - sepsis
S - scarlet fever
S - streptococcal pharyngitis P - parvovirus B19
P - pneumonia
P - pertussis
I - influenza
D - diptheria (pharyngeal) E - epiglottitis
R - rubella
M - mumps
M - meningitis
M - mycoplasma or meningeal pneumonia An - Adenovirus
Private Room
Cohort Mask – Pt wears mask when leaving the room
Disposable supplies
CONTACT PRECAUTION
MRS.WEE
M - multidrug resistant organism
R - respiratory infection
S - skin infections *
W - wound infxn
E - enteric infxn - clostridium difficile E - eye infxn – conjunctivitis
SKIN INFECTIONS VCHIPS
V - varicella zoster
C - cutaneous diphtheria H - herpez simplex
I - impetigo
P - pediculosis S – scabies
Private Room- Door Open
Gloves
Gown ONLY worn when in Direct Contact
Disposable supplies
1. Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic,
sense of impending doom) --> turn pt to left side and lower the head of the bed.
2. Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal bradycardia,
etc) --> turn on left side (and give O2, stop Pitocin, increase IV fluids)
3. Tube Feeding w/ Decreased LOC --> position pt on right side (promotes emptying of the
stomach ) with the HOB elevated (to prevent aspiration)
4. During Epidural Puncture --> side-lying
5. After Lumbar Puncture (and also oil-based Myelogram)--> pt lies in flat supine (to prevent
headache and leaking of CSF)
Downloaded by NELSON KIIRU ()
, lOMoAR cPSD| 26582732
6. Pt w/ Heat Stroke --> lie flat w/ legs elevated
7. During Continuous Bladder Irrigation (CBI) --> catheter is taped to thigh so leg should be kept
straight. No other positioning restrictions.
8. After Myringotomy --> position on side of affected ear after surgery (allows drainage of
secretions)
9. After Cataract Surgery --> pt will sleep on unaffected side with a night shield for 1-4 weeks.
10. After Thyroidectomy --> low or semi-Fowler's, support head, neck and shoulders.
11. Infant w/ Spina Bifida --> position prone (on abdomen) so that sac does not rupture
12. Buck's Traction (skin traction) --> elevate foot of bed for counter-traction
13. After Total Hip Replacement --> don't sleep on operated side, don't flex hip more than 45- 60
degrees, don't elevate HOB more than 45 degrees. Hip abduction by separating thighs with
pillows.
14. Prolapsed Cord --> knee-chest position or Trendelenburg
15. Infant w/ Cleft Lip --> position on back or in infant seat to prevent trauma to suture line. While
feeding, hold in upright position.
16. To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) --> eat in reclining
position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low CHO
and fiber diet, small frequent meals)
17. Above Knee Amputation --> elevate for first 24 hours on pillow, position prone daily to provide
for hip extension.
18. Below Knee Amputation --> foot of bed elevated for first 24 hours, position prone daily to
provide for hip extension.
19. Detached Retina --> area of detachment should be in the dependent position
20. Administration of Enema --> left side-lying (Sim's) with knee flexed
21. After Supratentorial Surgery (incision behind hairline) --> elevate HOB 30-45 degrees
22. After Infratentorial Surgery (incision at nape of neck)--> position pt flat and lateral on either
side.
Downloaded by NELSON KIIRU
()
